In the Name of God

Islamic Republic of IranIslamic Republic of Iran

Area:Area: 1648000 km1648000 km22

Population Population 66,000,000 66,000,000 (2002)(2002)

- Rural- Rural 2300000023000000- Urban- Urban3700000037000000

Province:Province: 3030 District:District: 280280 Village:Village: 65000 65000

<< Average distance Average distance

Between two villages:Between two villages: 25 km <25 km < Average populationAverage population Per village:350 >Per village:350 > GDP:114.1 billion GDP:114.1 billion

$(2001)$(2001)

Iranian Health IndicatorsIranian Health Indicators

IndicatorIndicator ValueValue

• Population growth ratePopulation growth rate 1.241.24• Total fertility rateTotal fertility rate 22

• EPI coverageEPI coverage 97%.97%.

• Infant mortality rateInfant mortality rate 28.628.6

• Infant breastfed for at least one yearInfant breastfed for at least one year 89%89%

• Maternal mortality rate Maternal mortality rate (per 100’000 live births)(per 100’000 live births) 37.437.4

• Life expectancy at birth Life expectancy at birth (years)(years) F:71F:71M:69M:69

Major Health Major Health Problems of IRAN : Problems of IRAN : (Similar To Other Countries)(Similar To Other Countries)

Inappropriate StructureInappropriate Structure Health Cost InflationHealth Cost Inflation Inappropriate QualityInappropriate Quality Non-fair FinancingNon-fair Financing Managerial ProblemsManagerial Problems Mismatch of Disease Burden & Mismatch of Disease Burden &

ExpendituresExpenditures

• Prevention Prevention / / cure Dissociationcure Dissociation• Macro – organizational Ambiguity,Macro – organizational Ambiguity, so conflicts of interests : so conflicts of interests :

Ambiguous role of health major role players especially GOV Ambiguous role of health major role players especially GOV try to do every thing, mostly delivers health services directly, try to do every thing, mostly delivers health services directly, policy making, supervision &… ; also, SSO goes in the same policy making, supervision &… ; also, SSO goes in the same wayway

• Highly centralized health systemHighly centralized health system• Fragmentation of Health systemFragmentation of Health system • Macro & Micro unfair Distribution of providersMacro & Micro unfair Distribution of providers

Inappropriate StructureInappropriate Structure

Iran Health Major Problems (1)Iran Health Major Problems (1)

Fragmentation of Health system

Prevention/cureDissociation •Integration in

Health Services (Family physician Unit)

& Health Funds (Virtual Fund)

Health Cost Inflation Health Cost Inflation

• High utilization high technology services High utilization high technology services • High direct contact with specialists & Weak High direct contact with specialists & Weak

referral system referral system • Cost escalating provider payment Cost escalating provider payment

mechanismsmechanisms• Irrational drug prescriptionIrrational drug prescription• Health package ambiguity Health package ambiguity • New Diseases & New Technologies New Diseases & New Technologies

Iran Health Major Problems (2)Iran Health Major Problems (2)

Cost escalating Provider Payment Mechanisms

( PPM )

High, Irrational utilization of Expensive Technology

Drugs, Lab & Graphies • Change in PPM to Capitation + Bonus

( Incentives )• CPGs on High

Cost Services

Inappropriate QualityInappropriate Quality

• Non standard Services ( No Guidelines )Non standard Services ( No Guidelines )• Irrational low service prices Irrational low service prices • Nonflexible hard budgetingNonflexible hard budgeting• Irrational drug prescription Irrational drug prescription • Highly centralized health system Highly centralized health system • Low outpatient visit durationLow outpatient visit duration

• Loose control mechanisms Loose control mechanisms • Decreasing responsibility & responsivenessDecreasing responsibility & responsiveness

Iran Health Major Problems (3)Iran Health Major Problems (3)

Loose Control Mechanisms

Nonstandard Services ( No Guidelines ) •Using CPGs

•Selective Contracting •P4P: Monitoring/Payment

Link with quality

Non-fair FinancingNon-fair Financing

• High % of catastrophic healthcare Expenditures High % of catastrophic healthcare Expenditures (CHE = 3.3%) even in insured(CHE = 3.3%) even in insured

• High Out of pocket payment of people (56%) High Out of pocket payment of people (56%) • Regressive Financing MethodRegressive Financing Method• Multiple Funds / Fragmentation Multiple Funds / Fragmentation • Low GOV Share in Health FundsLow GOV Share in Health Funds

Iran Health Major Problems (4)Iran Health Major Problems (4)

Multiple Funds Regressive Financing

Low GOV Share

High CHE 3.3High OOP 56%

•One Virtual Fund •Proportional Finance

Excise Tax (Tobacco,)

Managerial ProblemsManagerial Problems

• Weak RegulationWeak Regulation• Inefficient Decision making Inefficient Decision making • Mismatch of Authority & ResponsibilitiesMismatch of Authority & Responsibilities• Inflexible Public Rules Inflexible Public Rules • Less investment for evidencesLess investment for evidences• Opinion based decision makingOpinion based decision making• Outpatient data is not recorded Outpatient data is not recorded ((Health services & Health services &

Cost DataCost Data))• Non Unique Data DefinitionNon Unique Data Definition• Private Sector Data is unavailable Private Sector Data is unavailable

Iran Health Major Problems (5)Iran Health Major Problems (5)

Inefficient Decision making

Mismatch of Authority & Responsibilities

Lack of Valid Data •Decentralized FPU •Integration of Services •Patient File Data

•More Risk Transfer to Providers

Mismatch of Disease Mismatch of Disease Burden & ExpendituresBurden & Expenditures

• Burden toward Burden toward Chronic Diseases and AccidentsChronic Diseases and Accidents

• Expenditure toward Expenditure toward Hospital Care & Tertiary CareHospital Care & Tertiary Care Drug, Lab & GraphiesDrug, Lab & Graphies Acute Diseases Acute Diseases Less on Preventive MeasuresLess on Preventive Measures

Iran Health Major Problems (6)Iran Health Major Problems (6)

Expenditure on : Hospital & Tertiary Care (Expensive technology) Drug ,Lab & Graphies

Burden on :Chronic Diseases

and Accidents •Defining

Essential Health Benefit Packages

& Enforcing it

45 5570

96 100 93105

117140

158

195

236

310

351337

278

350

383

354

406

459442

335

368

396

358 354 354

9575

140166

215 221240

256

290

326

268253

265252 245

202

170 167 172

202

298283

268 266

214238

325 323

145

185

215

262

305 315

350373

440

484463

489

580603

582

480

540 550526

608

757

725

603

634610

596

679 677

0

100

200

300

400

500

600

700

800

كلهزينههايبهداشتودرمانبخشخصوصي كلهزينههايبهداشتودرمانبخشدولتي كلهزينههايبهداشتودرمان

بهميلياردريال

روند كل هزينه هاي بهداشت و درمان و هزينه هاي بهداشت و درمان در بخشهاي دولتي و خصوصي

سالهاي ( 1350 - 1378 ) - به قيمت هاي ثابت سال 1361

(1378 - حسابهاي ملي بهداشت و درمان ( 1350

Death rate estimation according to

death causes and mean age - 2000

800 death per day800 death per day

((300000 deaths per 300000 deaths per yearyear))

300

Cardiovascular

102Accident

80Cancer

32Peri-natal

Death

0.1Year

59.7Year

35.3year

68year

Design or plan a system to combine Design or plan a system to combine or integrate more of strategies / or integrate more of strategies / plan some options within them one plan some options within them one have to choose one option? Possibly have to choose one option? Possibly based on:based on:

• Potential benefits in the form of Potential benefits in the form of intermediate goals such as EQUITY.intermediate goals such as EQUITY.

• FeasibilityFeasibility• Political or Social AcceptabilityPolitical or Social Acceptability

DevelopingDevelopinga Solutiona Solution

Major Approaches Major Approaches to Health Systems :to Health Systems :

WHO FrameworkWHO Framework HSR CycleHSR Cycle Interactive Interactive Planning MethodPlanning Method

Stewardship(oversight)

Financing(collecting, pooling

and purchasing)

Creating resources(investment and training)

Delivering services

(Provision)

Responsiveness(to non-medicalexpectations)

Fair FinancialContribution

Health

Functions of the Health system

Ultimate Goals

EQUITY

EFFICIENCY

QUALITY

FISCAL IMPACT

ACCESS

Intermediate Goals

Control Knobs

Behavior

Regulation

Payment

Organization

Finance

Conscience

Developinga Solution

Design or plan a system to Design or plan a system to combine or integrate more of combine or integrate more of strategies / plan some options strategies / plan some options within them one have to choose within them one have to choose one option? Possibly based on:one option? Possibly based on:• Potential benefits in the form of Potential benefits in the form of

intermediate goals.intermediate goals.• FeasibilityFeasibility• Political or Social AcceptabilityPolitical or Social Acceptability

From Root Causes to Strategies

Inappropriate Structure

Health Cost Inflation Inappropriate

Quality

Non-fair Financing Managerial Problems Mismatch of Disease

Burden & Expenditures

Integration of Health Services & Funds

Change in PPM P4P:Monitoring/Payment

Link with quality Virtual Fund Proportional Finance

Decentralized FPU Integration of Services Patient File Data Risk Transfer to Provider Defining Essential Health

Packages & Enforcing it

From Strategies to a Plan: FP

Family Physician & Referral System

Plan

STRUCTURESTRUCTURE

•Integration of Health Services & Funds •Decentralized FPU

•Patient File Data•Health Data Dictionary•Health MIS

•Change in PPM •P4P:Monitoring/Payment Link with quality •Risk Transfer to Provider

•Defining Essential Health Packages

•Referral System•Selective Contracting•Monitoring with CPG•Gatekeeper GPs

•Virtual Fund•Proportional Finance•Increase GOV % Share

FINANCEFINANCE

PAYMENTPAYMENTPriority SettingPriority Setting

InformationInformation

MethodMethod

HSR Project ObjectivesHSR Project Objectives

1.1. To design and test a universal basic minimum To design and test a universal basic minimum health services package and strengthen patient health services package and strengthen patient referral system; referral system;

2.2. To assure stewardship and good governance in To assure stewardship and good governance in the public sector health system;the public sector health system;

3.3. To improve health planning and management To improve health planning and management including decentralization in the health sector including decentralization in the health sector by delegating administrative and financial by delegating administrative and financial authority; andauthority; and

4.4. To review the existing health financing options To review the existing health financing options for introducing measures to assure fair for introducing measures to assure fair financing, eliminating inefficiencies and bringing financing, eliminating inefficiencies and bringing equity.equity.

5.5. To build new capacities for Iranian experts to To build new capacities for Iranian experts to ensure participating in HSR & persistence of ensure participating in HSR & persistence of Reform;Reform;

6.6. To assure that HSR literature disseminated in To assure that HSR literature disseminated in the policymakers & stewards of the health the policymakers & stewards of the health system;system;

Important ActivitiesImportant Activities NHSRU, PHSRU NHSRU, PHSRU ((for conceptualising, formulating and for conceptualising, formulating and

implementing health sector reforms)implementing health sector reforms) Flagship Course: Harvard (9),Iran-Lorestan (4) Flagship Course: Harvard (9),Iran-Lorestan (4) Senior Policy Seminar (3)Senior Policy Seminar (3) Health Policy & Planning Course, TabrizHealth Policy & Planning Course, Tabriz Designing Family physician & Referral system Designing Family physician & Referral system

InstructionInstruction Piloting the instruction in BamPiloting the instruction in Bam Rural Insurance based on the InstructionRural Insurance based on the Instruction FellowshipFellowship Studies Studies STC’s (19)STC’s (19) Publication (6 Books)Publication (6 Books)

Other steps under the HSR Other steps under the HSR project umbrella project umbrella

Conduct the remaining flagship coursesConduct the remaining flagship courses Publishing the research proposals resultsPublishing the research proposals results Conducting Health Sector StudyConducting Health Sector Study Finding the gaps in the Health systemFinding the gaps in the Health system

to develop proposals and new projects for to develop proposals and new projects for the future action plan the future action plan

Publishing Health Sector Study resultsPublishing Health Sector Study results

HSR Performance: HSR Performance: New ChangesNew Changes

• More Practical & Community BasedMore Practical & Community Based

• More scientific BasedMore scientific Based

• National ConfidenceNational Confidence

• More Goal Specific esp. EQUITYMore Goal Specific esp. EQUITY